What is the recommended management approach for a 36-year-old G3 (Gravida 3) P2 (Para 2) patient with placenta accreta?

Management of Placenta Accreta in a 36-Year-Old G3P2 Patient

Your patient requires planned cesarean hysterectomy at 34-35 weeks gestation at a Level III/IV maternal care facility with a multidisciplinary team experienced in placenta accreta spectrum management. 1

Immediate Diagnostic Impression and Classification

• Document this as "Placenta Accreta Spectrum" - the current terminology that encompasses accreta, increta, and percreta 1
• Confirm the diagnosis and depth of invasion using gray-scale ultrasonography, which has sufficient sensitivity and specificity 2
• Consider MRI if ultrasound findings are ambiguous or to better delineate anatomy 2
• Assess for concurrent placenta previa, as the combination with prior cesarean delivery represents the highest risk scenario 3, 4

Delivery Location and Team Assembly

Transfer this patient immediately to a Level III or IV maternal care facility if you are not already at one, as outcomes are significantly optimized when delivery occurs at centers experienced with placenta accreta spectrum 1

Your multidisciplinary team must include 1:

• Maternal-fetal medicine specialists
• Gynecologic oncology or female pelvic medicine surgeons (for complex pelvic dissection)
• Anesthesiology with massive transfusion experience
• Neonatology
• Blood bank with massive transfusion protocol capability
• Interventional radiology (available but not routinely used)

Optimal Timing of Delivery

Schedule cesarean hysterectomy at 34 0/7 to 35 6/7 weeks gestation 1

The rationale for this specific window:

• Decision analysis demonstrates 34 weeks is optimal, balancing neonatal outcomes against maternal hemorrhage risk 1
• Approximately 50% of women beyond 36 weeks require emergent delivery for hemorrhage 1
• Do NOT wait beyond 36 0/7 weeks 1
• No amniocentesis is needed at this gestational age - pulmonary maturity testing does not change management 1

Administer antenatal corticosteroids for fetal lung maturation since delivery will occur before 37 weeks 1

Earlier delivery is indicated for 1:

• Persistent bleeding
• Preeclampsia
• Spontaneous labor
• Rupture of membranes
• Fetal compromise

Preoperative Optimization

Hematologic Preparation

Coordinate with blood bank for massive transfusion protocol - blood loss estimates vary widely but can be massive 1

Optimize hemoglobin preoperatively 1:

• Evaluate and treat iron deficiency anemia aggressively
• Use oral iron replacement
• Consider intravenous iron infusions
• Consider erythropoietin-stimulating agents when indicated
• Autologous blood donation is NOT routinely recommended 1

Activity Modifications

Activity restriction and pelvic rest have unproven benefit - individualize this decision based on bleeding symptoms rather than routine recommendation 1

Surgical Management Approach

The gold standard is planned cesarean hysterectomy with placenta left in situ 1, 2

Critical surgical principles 1, 2:

• Do NOT attempt placental removal - this is associated with significant hemorrhagic morbidity 1, 2
• Deliver the fetus through a uterine incision that avoids the placenta when possible
• Ligate the umbilical cord close to the placenta
• Proceed directly to hysterectomy without attempting placental separation
• Have massive transfusion protocol activated and ready

Intraoperative Hemorrhage Management

If massive bleeding occurs 5:

• Transfuse in 1:1:1 ratio (packed RBCs:FFP:platelets) 5
• Consider tranexamic acid to reduce blood loss 5
• Monitor fibrinogen levels closely 5
• Maintain maternal temperature >36°C for optimal clotting factor function 5

Alternative Management (NOT Recommended as First-Line)

Conservative/Expectant Management

This is investigational and carries significant risks - only consider in exceptional circumstances 1

The data show 1:

• 22-42% still require hysterectomy
• 28% develop infection/febrile morbidity
• 6% experience severe morbidity (sepsis, organ failure, death)
• Median time to placental involution is 13.5 weeks
• 70% of severe morbidity cases involve maternal sepsis

I strongly advise against expectant management given these risks and the lack of robust evidence supporting this approach 1

Emergency Contingency Planning

Despite planned delivery, develop an emergency protocol for unexpected hemorrhage before scheduled delivery 2, 6:

• Establish protocols for maternal hemorrhage management
• Ensure 24/7 availability of surgical team
• Have blood products immediately available
• Consider temporizing measures: uterine packing, tranexamic acid infusion, and local transfusion if transfer needed 1

Postoperative Care

• Plan for potential ICU monitoring given risks of ongoing bleeding, fluid overload, and renal failure 5
• Maintain low threshold for reoperation if ongoing bleeding suspected 5
• Monitor for delayed complications including infection and thromboembolic events

Critical Pitfalls to Avoid

• Never attempt manual placental removal - this causes catastrophic hemorrhage 1, 2
• Do not delay delivery beyond 36 weeks in a stable patient 1
• Do not deliver at a facility without massive transfusion capability 1
• Do not confuse this with less serious placental abnormalities like placenta circumvallata 7
• Do not pursue conservative management without extensive counseling about the 22-42% hysterectomy rate and infection risks 1